Healthcare Provider Details

I. General information

NPI: 1730699976
Provider Name (Legal Business Name): LISA D BLAKE LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 10/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 E BURNSIDE ST STE 213
PORTLAND OR
97214-1768
US

IV. Provider business mailing address

5319 SE 69TH AVE
PORTLAND OR
97206-5343
US

V. Phone/Fax

Practice location:
  • Phone: 503-234-4288
  • Fax:
Mailing address:
  • Phone: 603-219-1318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number18230
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: